- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.29 / $137.41 / $218.56
| Professional | | $126.29 | $137.41 | $218.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.87 / $129.87 / $210.85
| Professional | | $129.87 | $129.87 | $210.85 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $129.87 / $129.87 / $160.55
| Facility | 26 | $129.87 | $129.87 | $160.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.97 / $188.45 / $270.54
| Professional | | $159.97 | $188.45 | $270.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $129.87 / $129.87 / $160.55
| Facility | 26 | $129.87 | $129.87 | $160.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.40 / $183.32 / $247.23
| Professional | | $129.40 | $183.32 | $247.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.25 / $124.43 / $248.45
| Professional | | $120.25 | $124.43 | $248.45 |